Clinical decision support in promoting evidence-based nursing in primary healthcare: a cross-sectional study in Finland

INTRODUCTION AND AIMS

The aim was to explore clinical decision support (CDS) use in the practice of primary healthcare nurses. The objectives were to recognize to what extent nurses (registered nurses, public health nurses, and practical nurses) use CDS, what factors were associated with the CDS used, what kind of organizational support nurses need, and what were nurses' views about CDS development needs.

METHODS

The study was conducted with a cross-sectional study design, using an electronic questionnaire developed for this purpose. The questionnaire contained 14 structured questions and nine open-ended questions. The sample consisted of randomly selected primary healthcare organizations ( N  = 19) in Finland. Quantitative data were analyzed using cross-tabulation and Pearson's chi-squared test, and qualitative data with quantification.

RESULTS

A total of 267 healthcare professionals (age range 22-63 years) volunteered to participate. Participants were mainly registered nurses, public health nurses, and practical nurses (46.8, 24, and 22.9%, respectively). Overall, 59% of the participants had never used CDS. The majority (92%) found it necessary to develop nursing-specific content for CDS. The most commonly used features were medication recommendations and warnings (74%), reminders (56%), and calculators (42%). Half of the participants (51%) had not received training on the use of CDS. The older age of participants was associated with the feeling of not having enough training to use CDS ( P  = 0.039104). Nurses felt that CDS was helpful in their clinical work and decision-making, promoting evidence-based practice, and narrowing the research-into-practice gap, improving patient safety and the quality of care, and helping those who are new in their work.

CONCLUSION

CDS and its support structures should be developed from a nursing perspective to achieve the full potential of CDS in nursing practice.

Nursing interventions in preventing pressure injuries in acute inpatient care: a cross-sectional national study

BACKGROUND

Several nursing interventions for pressure injury prevention have been identified, including risk and skin status assessment. The aim of this study was to explore prevention of pressure injuries in Finnish acute inpatient care. The data were collected on pressure injury risk and skin status assessments, repositioning, the use of support surfaces, preventive skin care, malnutrition risk assessment, and nutritional care.

METHODS

This multicentre, cross-sectional study was conducted in 16 acute care hospitals, excluding psychiatric care. Adult patients from inpatient care were recruited on the annual international Stop Pressure Ulcers Day in 2018 and 2019. Enrolment covered 6,160 participants in 503 units. Descriptive statistics were used to describe pressure injuries, risk assessments, and preventive nursing interventions. Cross tabulation, Pearson's chi-square and Fisher's exact tests were also used. Reporting follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

RESULTS

In all, 30% of the participants had their pressure injury risk assessed during the care, and for 19% within 8 h after admission. The same time limit in risk assessment was fulfilled for 16% of the participants with a pressure injury, and 22% of the participants using a wheelchair or being bedridden. A skin status assessment within 8 h after admission was conducted for 30% of all participants, and for 29% of the participants with a pre-existing pressure injury, and for 38% of the participants using a wheelchair or being bedridden. The risk of malnutrition was screened in 20% of the participants. Preventive interventions were targeted to participants with a pressure injury instead of patients with a high-pressure injury risk.

CONCLUSION

This study adds evidence about pressure injury risk assessments and the implementation of preventive nursing interventions in Finnish acute care. Skin status and pressure injury risk assessments were irregularly conducted, and the outcome was not used by nurses to guide the implementation of preventive interventions. The results reveal the gaps in evidence-based nursing practice, which require further efforts to prevent pressure injuries. Improving the national focus on pressure injury prevention practice is critical for improving healthcare for our patients.

The perceptions of different professionals on school absenteeism and the role of school health care: A focus group study conducted in Finland

Purpose of the study

School absenteeism and school dropout jeopardize the future health and wellbeing of students. Reports on the participation of school health care in absenteeism reduction are infrequent, although physical and mental health problems are the most common causes of school absenteeism. Our aim was to explore what reasons different professionals working in schools recognize for absenteeism and which factors either promote or inhibit the inclusion of school health care in absenteeism reduction.

Materials and methods

Data for this qualitative study was gathered from ten focus groups conducted in two municipalities in southern Finland. The groups included (vice) principals, special education/resource/subject teachers, guidance counselors, school social workers, school psychologists, school nurses, school doctors, and social workers working in child protective services. Data analysis was predominantly inductive but the categorization of our results was based on existing literature.

Results

Study participants identified student-, family-, and school-related reasons for absenteeism but societal reasons went unmentioned. A number of reasons promoting the inclusion of school health care in absenteeism reduction arose, such as expertise in health-related issues and the confidentiality associated with health care. Inclusion of school health care was hindered by differences in work culture and differing perceptions regarding the aims of school health care.

Conclusion

Professionals working in schools were knowledgeable about the different causes of school absenteeism. Clarifying both the aims of school health care and the work culture of different professionals could facilitate the inclusion of school health care in absenteeism reduction.

Professionals' views on patient involvement in acute psychiatric wards: A qualitative study

PURPOSE

To examine multiprofessionals' views on patient involvement in acute psychiatric wards.

DESIGN AND METHODS

The study was conducted in four hospital districts in Finland. The data were collected between December 2016 and March 2017 by means of four focus group interviews and analyzed with inductive content analysis.

FINDINGS

The five main themes emerged: Patient-, carer-, professional-, hospital-, and healthcare system-related factors enhancing or preventing patient involvement in acute psychiatric wards.

PRACTICE IMPLICATIONS

The findings confirm that many obstacles need to be removed in ward practice before patient involvement can really be made a part of the daily routine.

Service users' views regarding user involvement in mental health services: A qualitative study

BACKGROUND

Service user involvement is emphasised in many strategies, plans and declarations globally. However, in practice, service user involvement is not always achieved and remains at a tokenistic level.

OBJECTIVES

To explore the views of service users on user involvement in mental health service.

DESIGN

Explorative descriptive study design.

SETTING

The study was conducted in one psychiatric hospital and in two mental health organisations in western Finland.

METHODS

The data was generated through three focus group interviews and analysed with qualitative content analysis.

RESULTS

User involvement means that people using mental health services are respected, listened to and can act in co-operation with professionals so than they feel that they can influence their own care and treatment. The participants articulated concrete factors that promote or inhibit user involvement. Service user involvement can be enhanced by strengthening service users´ position, by developing the mental health care system and by specific training for professionals.

CONCLUSIONS

The views of service users in this study concerning the realisation of user involvement and the factors promoting and preventing it were realistic. They are basic elements of patient-centred care and of all human interaction. Our participants described service user involvement in their own care and treatment. They emphasised the need to have more information, and wanted to be more involved in decision-making about their own care and treatment. They called for better care planning and co-ordination as one way to increase service user involvement. These also have implications for mental health services at the system level.

A systematic review of trials evaluating success factors of interventions with computerised clinical decision support

BACKGROUND

Computerised clinical decision support (CDS) can potentially better inform decisions, and it can help with the management of information overload. It is perceived to be a key component of a learning health care system. Despite its increasing implementation worldwide, it remains uncertain why the effect of CDS varies and which factors make CDS more effective.

OBJECTIVE

To examine which factors make CDS strategies more effective on a number of outcomes, including adherence to recommended practice, patient outcome measures, economic measures, provider or patient satisfaction, and medical decision quality.

METHODS

We identified randomised controlled trials, non-randomised trials, and controlled before-and-after studies that directly compared CDS implementation with a given factor to CDS without that factor by searching CENTRAL, MEDLINE, EMBASE, and CINAHL and checking reference lists of relevant studies. We considered CDS with any objective for any condition in any healthcare setting. We included CDS interventions that were either displayed on screen or provided on paper and that were directed at healthcare professionals or targeted at both professionals and patients. The reviewers screened the potentially relevant studies in duplicate. They extracted data and assessed risk of bias in independent pairs or individually followed by a double check by another reviewer. We summarised results using medians and interquartile ranges and rated our certainty in the evidence using the GRADE system.

RESULTS

We identified 66 head-to-head trials that we synthesised across 14 comparisons of CDS intervention factors. Providing CDS automatically versus on demand led to large improvements in adherence. Displaying CDS on-screen versus on paper led to moderate improvements and making CDS more versus less patient-specific improved adherence modestly. When CDS interventions were combined with professional-oriented strategies, combined with patient-oriented strategies, or combined with staff-oriented strategies, then adherence improved slightly. Providing CDS to patients slightly increased adherence versus CDS aimed at the healthcare provider only. Making CDS advice more explicit and requiring users to respond to the advice made little or no difference. The CDS intervention factors made little or no difference to patient outcomes. The results for economic outcomes and satisfaction outcomes were sparse.

CONCLUSION

Multiple factors may affect the success of CDS interventions. CDS may be more effective when the advice is provided automatically and displayed on-screen and when the suggestions are more patient-specific. CDS interventions combined with other strategies probably also improves adherence. Providing CDS directly to patients may also positively affect adherence. The certainty of the evidence was low to moderate for all factors.

TRIAL REGISTRATION

PROSPERO, CRD42016033738.

The GUIDES checklist: development of a tool to improve the successful use of guideline-based computerised clinical decision support

Background

Computerised decision support (CDS) based on trustworthy clinical guidelines is a key component of a learning healthcare system. Research shows that the effectiveness of CDS is mixed.

Multifaceted context, system, recommendation and implementation factors may potentially affect the success of CDS interventions. This paper describes the development of a checklist that is intended to support professionals to implement CDS successfully.

Methods

We developed the checklist through an iterative process that involved a systematic review of evidence and frameworks, a synthesis of the success factors identified in the review, feedback from an international expert panel that evaluated the checklist in relation to a list of desirable framework attributes, consultations with patients and healthcare consumers and pilot testing of the checklist.

Results

We screened 5347 papers and selected 71 papers with relevant information on success factors for guideline-based CDS. From the selected papers, we developed a 16-factor checklist that is divided in four domains, i.e. the CDS context, content, system and implementation domains. The panel of experts evaluated the checklist positively as an instrument that could support people implementing guideline-based CDS across a wide range of settings globally. Patients and healthcare consumers identified guideline-based CDS as an important quality improvement intervention and perceived the GUIDES checklist as a suitable and useful strategy.

Conclusions

The GUIDES checklist can support professionals in considering the factors that affect the success of CDS interventions. It may facilitate a deeper and more accurate understanding of the factors shaping CDS effectiveness. Relying on a structured approach may prevent that important factors are missed.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0772-3) contains supplementary material, which is available to authorized users.

Development of a Tailored Intervention With Computerized Clinical Decision Support to Improve Quality of Care for Patients With Knee Osteoarthritis: Multi-Method Study

BACKGROUND

Clinical practice patterns greatly diverge from evidence-based recommendations to manage knee osteoarthritis conservatively before resorting to surgery.

OBJECTIVE

This study aimed to tailor a guideline-based computerized decision support (CDS) intervention that facilitates the conservative management of knee osteoarthritis.

METHODS

Experts with backgrounds in clinical medicine, research, implementation, or health informatics suggested the most important recommendations for implementation, how to develop an implementation strategy, and how to form the CDS algorithms. In 6 focus group sessions, 8 general practitioners and 22 patients from Norway, Belgium, and Finland discussed the suggested CDS intervention and identified factors that would be most critical for the success of the intervention. The focus group moderators used the GUideline Implementation with DEcision Support checklist, which we developed to support consideration of CDS success factors.

RESULTS

The experts prioritized 9 out of 22 recommendations for implementation. We formed the concept for 6 CDS algorithms to support implementation of these recommendations. The focus group suggested 59 unique factors that could affect the success of the presented CDS intervention. Five factors (out of the 59) were prioritized by focus group participants in every country, including the perceived potential to address the information needs of both patients and general practitioners; the credibility of CDS information; the timing of CDS for patients; and the need for personal dialogue about CDS between the general practitioner and the patient.

CONCLUSIONS

The focus group participants supported the CDS intervention as a tool to improve the quality of care for patients with knee osteoarthritis through shared, evidence-based decision making. We aim to develop and implement the CDS based on these study results. Future research should address optimal ways to (1) provide patient-directed CDS, (2) enable more patient-specific CDS within the context of patient complexity, and (3) maintain user engagement with CDS over time.

Attitudes of mental health professionals towards service user involvement

Patient-centred care and user involvement in healthcare services are much emphasised globally. This study was the first step in a multicentre research project in Finland to improve service users' and carers' opportunities to be more involved in mental health services. The aim of the study was to assess attitudes of professionals towards service user involvement. The data were collected via an online questionnaire from 1069 mental health professionals in four hospital districts. Altogether, 351 professionals responded. Data were analysed using appropriate statistical methods. According to the results, attitudes of healthcare professionals were more positive towards service users' involvement in their own treatment than in other levels of services. There were also differences in gender, age groups, working places and experiences in the attitudes of professionals concerning service users' involvement in their own treatment. These should be taken into account in the future when planning education for mental health professionals. In spite of governmental guidance on service user involvement and the growing body of knowledge of the benefits associated with it, change in attitudes towards user involvement is slow. Special attention should be paid to the attitudes of professionals working in inpatient care and of those with less working experience.

Tailoring implementation strategies for evidence-based recommendations using computerised clinical decision support systems: protocol for the development of the GUIDES tools

Background

A computerised clinical decision support system (CCDSS) is a technology that uses patient-specific data to provide relevant medical knowledge at the point of care. It is considered to be an important quality improvement intervention, and the implementation of CCDSS is growing substantially. However, the significant investments do not consistently result in value for money due to content, context, system and implementation issues. The Guideline Implementation with Decision Support (GUIDES) project aims to improve the impact of CCDSS through optimised implementation based on high-quality evidence-based recommendations. To achieve this, we will develop tools that address the factors that determine successful CCDSS implementation.

Methods/design

We will develop the GUIDES tools in four steps, using the methods and results of the Tailored Implementation for Chronic Diseases (TICD) project as a starting point: (1) a review of research evidence and frameworks on the determinants of implementing recommendations using CCDSS; (2) a synthesis of a comprehensive framework for the identified determinants; (3) the development of tools for use of the framework and (4) pilot testing the utility of the tools through the development of a tailored CCDSS intervention in Norway, Belgium and Finland. We selected the conservative management of knee osteoarthritis as a prototype condition for the pilot. During the process, the authors will collaborate with an international expert group to provide input and feedback on the tools.

Discussion

This project will provide guidance and tools on methods of identifying implementation determinants and selecting strategies to implement evidence-based recommendations through CCDSS. We will make the GUIDES tools available to CCDSS developers, implementers, researchers, funders, clinicians, managers, educators, and policymakers internationally. The tools and recommendations will be generic, which makes them scalable to a large spectrum of conditions. Ultimately, the better implementation of CCDSS may lead to better-informed decisions and improved care and patient outcomes for a wide range of conditions.

Protocol registration

PROSPERO, CRD42016033738

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0393-7) contains supplementary material, which is available to authorized users.

Patient-specific computer-based decision support in primary healthcare--a randomized trial

BACKGROUND

Computer-based decision support systems are a promising method for incorporating research evidence into clinical practice. However, evidence is still scant on how such information technology solutions work in primary healthcare when support is provided across many health problems. In Finland, we designed a trial where a set of evidence-based, patient-specific reminders was introduced into the local Electronic Patient Record (EPR) system. The aim was to measure the effects of such reminders on patient care. The hypothesis was that the total number of triggered reminders would decrease in the intervention group compared with the control group, indicating an improvement in patient care.

METHODS

From July 2009 to October 2010 all the patients of one health center were randomized to an intervention or a control group. The intervention consisted of patient-specific reminders concerning 59 different health conditions triggered when the healthcare professional (HCP) opened and used the EPR. In the intervention group, the triggered reminders were shown to the HCP; in the control group, the triggered reminders were not shown. The primary outcome measure was the change in the number of reminders triggered over 12 months. We developed a unique data gathering method, the Repeated Study Virtual Health Check (RSVHC), and used Generalized Estimation Equations (GEE) for analysing the incidence rate ratio, which is a measure of the relative difference in percentage change in the numbers of reminders triggered in the intervention group and the control group.

RESULTS

In total, 13,588 participants were randomized and included. Contrary to our expectation, the total number of reminders triggered increased in both the intervention and the control groups. The primary outcome measure did not show a significant difference between the groups. However, with the inclusion of patients followed up over only six months, the total number of reminders increased significantly less in the intervention group than in the control group when the confounding factors (age, gender, number of diagnoses and medications) were controlled for.

CONCLUSIONS

Computerized, tailored reminders in primary care did not decrease during the 12 months of follow-up time after the introduction of a patient-specific decision support system.

TRIAL REGISTRATION

ClinicalTrial.gov NCT00915304.

Clinical decision support must be useful, functional is not enough: a qualitative study of computer-based clinical decision support in primary care

Background

Health information technology, particularly electronic decision support systems, can reduce the existing gap between evidence-based knowledge and health care practice but professionals have to accept and use this information. Evidence is scant on which features influence the use of computer-based clinical decision support (eCDS) in primary care and how different professional groups experience it. Our aim was to describe specific reasons for using or not using eCDS among primary care professionals.

Methods

The setting was a Finnish primary health care organization with 48 professionals receiving patient-specific guidance at the point of care. Multiple data (focus groups, questionnaire and spontaneous feedback) were analyzed using deductive content analysis and descriptive statistics.

Results

The content of the guidance is a significant feature of the primary care professional’s intention to use eCDS. The decisive reason for using or not using the eCDS is its perceived usefulness. Functional characteristics such as speed and ease of use are important but alone these are not enough. Specific information technology, professional, patient and environment features can help or hinder the use.

Conclusions

Primary care professionals have to perceive eCDS guidance useful for their work before they use it.

Healthcare professionals' intentions to use clinical guidelines: a survey using the theory of planned behaviour

Background

Finnish clinical guidelines are evolving toward integration of knowledge modules into the electronic health record in the Evidence-Based Medicine electronic Decision Support project. It therefore became important to study which factors affect professionals' intention to use clinical guidelines generally in their decision-making on patient care. A theory-based approach is a possible solution to explore determinants of professionals' behaviour. The study's aim was to produce baseline information for developers and implementers by using the theory of planned behaviour.

Methods

A cross-sectional internet-based survey was carried out in Finnish healthcare organisations within three hospital districts. The target population (n = 2,252) included physicians, nurses, and other professionals, of whom 806 participated. Indicators of the intention to use clinical guidelines were observed by using a theory-based questionnaire. The main data analysis was done by means of multiple linear regressions.

Results

The results indicated that all theory-based variables--the attitude toward the behaviour, the subjective norm, and the perceived behaviour control--were important factors associated with the professionals' intention to use clinical practice guidelines for their area of specialisation in the decisions they would make on the care of patients in the next three months. In addition, both the nurse and the physician factors had positive (p < 0.01) effects on this intention in comparison to other professionals. In the similar models for all professions, the strongest factor for the physicians was the perceived behaviour control, while the key factor for the nurses and the other professionals was the subjective norm. This means that context- and guideline-based factors either facilitate or hinder the intention to use clinical guidelines among physicians and, correspondingly, normative beliefs related to social pressures do so for nurses and other healthcare professionals.

Conclusions

The results confirm suggestions that the theory of planned behaviour is a suitable theoretical basis for implementing clinical guidelines in healthcare practices. Our new finding was that, in general, profession had an effect on intention to use clinical guidelines in patient care. Therefore, the study reaffirms the general contention that different strategies need to be in place when clinical guidelines are targeted at different professional groups.

What may help or hinder the implementation of computerized decision support systems (CDSSs): a focus group study with physicians

OBJECTIVES

To identify potential barriers and facilitators to implementing computerized decision support systems (CDSSs) in health care as perceived by clinicians.

METHODS

We carried out a qualitative focus group study with primary and secondary health care settings in six areas of Finland. A total of 39 interviewed physicians, of whom 22 practised in primary care and 17 in secondary care. The main outcome measures physicians' expectations, preconceived barriers and facilitators were explicitly identified by the participants during the interviews.

RESULTS

Identified barriers were earlier experience of dysfunctional computer systems in health care, potential harm to doctor-patient relationship, obscured responsibilities, threats to clinician's autonomy and potential extra workload due to excessive reminders. Identified facilitators were self-control of frequency and contents of CDSS and noticeable help of CDSS in clinical practice. It was easy for the physicians to think of applications and clinical topics for CDSS that could help them to avoid mistakes and improve work processes.

CONCLUSIONS

Physicians had relatively positive attitudes towards the idea of CDSS. They expected flexibility, individuality and reliability of the CDSS. The rather high level of computerized practices and wide use of electronic guidelines probably have paved the way for the CDSS in Finland.